History and Physical Examination Essay

Admitting Diagnosis Stomatitis possibly methotrexate related Chief Complaint gawk of lips causing obstacle swallowing History of Present Illness This patient is a 57-year-old Cuban woman with a long history of rheumatoid arthritis. She has received methotrexate on a weekly basis as an outpatient for many years. Approximately two weeks ago she developed a respiratory infection for which she received antibiotics and realised that course of antibiotics. She developed some ulceration of her mouth and was instructed to discontinue the methotrexate approximately 10 geezerhood ago. She showed some initial improvement however over the last 3-5 daytimes has had malaise, a low-grade feverishness and severe oral alterations with difficulty in swallowing although she can drink liquids with less difficulty. patient role denies any different problems at this point except for flare of arthritis since discontinuing the methotrexate. She has rather diffused pain involving both large and clar ified joints this has caused her some anxiety. Medications Prednisone 7.5 mg PO daily. Estradiol 0.5 mg PO QAM. Mobic 7.5 mg PO daily. deep discontinued because of doubtful allergic reaction HCTZ 25 mg PO every other day and oral calcium supplements. In the past she has been on penc brainsickamine, azathioprine and hydroxychloroquine but she has not had Azulfidine, cyclophosphamide or chlorambucil.Allergies none by historyFamily and Social History noncontributoryPhysical Examination This is a chronically ill appearing female alert oriented and cooperative. She moves with great difficulty because of fatigue and malaise. Vital Signs Blood compress 107/80. Heart rate 100 and regular respirations 22. HEENT normal cephalic. No scalp lesions. Dried eyes withconjuctival injection. mild exophthalmos. Dry nasal mucosa. Mark cracking bleeding in her lips with erosions of the mucosa. She has a large ulceration of the mucosa at the bite margin on the left. She has some scattered ulceration s on her heart and soft pallets. She has difficulty opening her mouth because of pain. Tonsils not enlarged. No visible exudate. Skin She has some mild ecchymosis on her flake and some erythema. She has patches but no obvious skin break down. She has some fissuring in the buttix crease. Pulmonary exempt to precaution and alcostation bilaterally. Cardiovascular No murmurs or galaps noted.Abdomen Soft. None tender. Protuberant no organomegaly and positive gut sounds. Neurologic Exam Cranial nerves 2-12 are grossly intact. Diffuse hyporeflexia. Muscular Skeletal sulphurous destructive changes in the elbows, wrists, and hands consistent with rheumatoid arthritis. Has bilateral total knee replacements with stovepipe legs and perimalleolar roughness edema 1 +. I feel no pulses distally in either leg. Psychiatric Patient is a little anxious about these new symptoms and their significance. We discussed her situation and I offered her psychological services. She refused for now.Problems 1. Swelling of lips and dysphasia with questionable early Stevens- Johnsons syndrome.2. Rheumatoid arthritis class 3 stage 4.3. Flare of arthritis after discontinuing methotrexate.4. Osteoporosis with compression fracture.5. Mild dehydration.6. Nephrolithiasis.7. Anxiety. political platform1. Admit patient for IV hydration and treatment of oral ulcerations.2. Obtain a dermatology consult.3. IV leucovorin will be started and the patient will be put on high dose corticosteroids.4. Considering patients anxiety perhaps harbor services of Stella Rose Dickinson PHD Psychology at a later date.X______________________________________________Liam Medina, MD get wind 06/22/- plate Study 5 Discharge SummaryPatient Name Fanny CopelandPatient ID 115463Date of put up 10/26/Age 58Sex FemaleDate of Admission 04/26/-Date of Discharge 05/01/-Procedure Performed CT scan.Ms. Copeland is seen for her summary conference from her work up here at Hillcrest reposition Diagnostic Center. I initially saw he r on 04/28/- at which time there was the suspiciousness of depression. She has since had CAT scan of the brain with contrast of 04/30/- which was unremarkable. Laboratories studies were completely negative to include normal thyroid gland function B12 and RPR. She had a formal neurophysiological battery with Dr. Stella Dickinson on 04/26/- she scored 136 on the dementia judge scale, which is within normal limits for her age.The test result were consistent with mild cognitive defaces manifested by problems with concept formation. tending and concentration and verbal computer storage. However the patient is significantly depressed which can produce some memory problems. Her past MRI suggests someone who is experiencing stress. Impression There was no clinical evidence of dementia but there is evidence of a depressive disorder as the cause of her symptom etiology. No further dangerous or homicidal ideation are present. Recommendations We recommend a psychiatric evaluation and treatm ent with re-testing in our quickness in one years time.